Individual
CHARLES THEODOROVICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
30200 TELEGRAPH RD, SUITE 220, BINGHAM FARMS, MI 48025-4502
(248) 258-5058
Mailing address
321 N GORDON ST, MARSHALL, MI 49068-1214
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
4704101769
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104831359
—
MI
01
—
P00309996
RAILROAD MEDICARE
MI
Enumeration date
05/01/2006
Last updated
04/01/2014
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